Provider Demographics
NPI:1700596640
Name:EATON, ELLIE KRISTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:KRISTIN
Last Name:EATON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:KRISTIN
Other - Last Name:LYTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3397 PIPER RD
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-4732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:989-356-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011497363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical